— 健康促進與維護 · MEDIUM · MCQ —
護理師照顧一位對新藥物產生過敏反應的成人病人。優先採取的行動為何？
A nurse is caring for an adult client who has developed an allergic reaction to a new medication. What is the priority action?
- ANotify the physician通知醫師
- BDocument the incident in the chart在病歷中記錄事件
- CAdminister an antihistamine給予抗組織胺
- DStop the medication infusion immediately✓ 正解立即停止藥物輸注
— Explanation · 中文詳解 —
過敏反應發生時，優先移除過敏原（Stop infusion）以避免反應持續惡化是護理的第一要務。隨後才是評估生命徵象、給予緊急藥物（Antihistamine/Epinephrine）並通知醫師。這是標準的 ABC 原則與防護程序。
When an allergic reaction occurs, the priority is to remove the allergen (stop the infusion) to prevent the reaction from continuing to worsen; this is the first nursing action. This is followed by assessing vital signs, administering emergency medications (antihistamine/epinephrine), and notifying the physician. This follows the standard ABC principle and safety protocol.
✦ 台美臨床差異
美國護理師在嚴重過敏反應（Anaphylaxis）下可依 protocol 使用腎上腺素，台灣則通常需醫師確認或緊急醫囑。